Can naltrexone be added to a patient's regimen of bupropion (Wellbutrin) 150mg twice daily (BID) who is requesting contrave (naltrexone-bupropion)?

From the Guidelines

It is not recommended to simply add naltrexone to Wellbutrin (bupropion) 150 mg BID as a substitute for Contrave, instead the patient should discontinue their current Wellbutrin regimen and start the Contrave titration schedule as prescribed. Contrave is a specific combination product containing bupropion 90 mg and naltrexone 8 mg in each tablet, with a gradual titration schedule 1. The patient would need to start with one tablet in the morning for one week, then add an evening dose in week 2, and gradually increase to two tablets twice daily by week 4, as recommended in the AGA clinical practice guideline on pharmacological interventions for adults with obesity 1. This specific dosing and combination has been studied for weight management, whereas simply adding naltrexone to the current Wellbutrin dose would not follow the FDA-approved regimen. Some key points to consider when prescribing Contrave include:

• The recommended titration schedule to minimize side effects like nausea, headache, and insomnia 1
• Contraindications, such as opioid use, severe renal or hepatic impairment, and epilepsy 1
• Potential benefits for patients with depressed mood or those needing assistance with smoking cessation 1
• The need for monitoring vital signs and avoiding use in patients with uncontrolled hypertension or those treated with monoamine oxidase inhibitors 1 A healthcare provider should evaluate the patient's specific situation, including their reason for wanting Contrave (typically weight management), and determine the appropriate approach, taking into account the potential benefits and risks of the medication 1.

From the FDA Drug Label

Naltrexone hydrochloride should be considered as only one of many factors determining the success of treatment of alcoholism. To achieve the best possible treatment outcome, appropriate compliance-enhancing techniques should be implemented for all components of the treatment program, especially medication compliance. A dose of 50 mg once a day will produce adequate clinical blockade of the actions of parenterally administered opioids. If signs of opioid withdrawal are still observed following naloxone challenge, treatment with, naltrexone hydrochloride should not be attempted.

The patient is on Wellbutrin 150 BID and wants to add Contrave, which contains bupropion (the same active ingredient as Wellbutrin) and naltrexone.

• Key consideration: The patient is already taking Wellbutrin, which is a component of Contrave.
• Main concern: There is no direct information in the provided drug label about adding naltrexone to a patient already taking Wellbutrin who wants to start Contrave. The FDA drug label does not answer the question.

From the Research

Patient's Current Medication and Request

• The patient is currently taking Wellbutrin 150 BID and wants to add Contrave.
• Contrave is a combination of naltrexone and bupropion, which are both already present in the patient's current medication regimen (bupropion is the active ingredient in Wellbutrin).

Safety and Efficacy of Naltrexone and Bupropion Combination

• Studies have shown that the combination of naltrexone and bupropion is effective for weight loss, with a placebo-subtracted weight loss of around 4.5% 2.
• The safety profile of this combination is acceptable, despite additional data regarding cardiovascular disease being needed 2.
• A pooled analysis of clinical trials found that anxiety and sleep disorder-related psychiatric adverse events were more frequent with naltrexone/bupropion versus placebo, but were mostly mild to moderate and generally occurred early 3.
• Another study found that naltrexone/bupropion treatment combined with lifestyle intervention resulted in significant weight loss after 6 and 12 months, despite high discontinuation rates due to side effects 4.

Considerations for Adding Naltrexone to the Patient's Current Medication

• Since the patient is already taking bupropion (Wellbutrin), adding naltrexone to their regimen would essentially be adding Contrave to their current medication.
• The patient's healthcare provider should carefully consider the potential benefits and risks of adding naltrexone to their current medication regimen, including the potential for increased side effects such as nausea, vomiting, headaches, and constipation 4.
• The healthcare provider should also monitor the patient's response to the medication and adjust the treatment plan as needed to minimize adverse events and maximize weight loss benefits 5.